Paediatrics Clinical Guide - Comprehensive Version 14

🩺 Paediatrics Clinical Guide

Comprehensive clinical reference for primary care - Version 14 Complete

🚨 Emergency
Protocols

🚦 Traffic Light
System

💊 Drug
Dosages

📊 Assessment
Tools

🛡️ Safeguarding
Guidance

📈 Development
Milestones

🤒 The Sick Child 🚦 Traffic Light System 🚨 Emergencies 🩺 Clinical Conditions 👶 The Normal Child 🛡️ Safeguarding

🧠 Learning Points

Trust parents - they know their child better than anyone
Age matters: <3 months with fever = urgent assessment
Kids can dip and recover - that's normal. What's NOT normal is dipping and not coming back up
Safety net always: When to return, what to watch for
Document concerns: Especially safeguarding worries
When in doubt: Discuss with paediatrics or senior colleague
Growth charts: Crossing centiles down = concern
Development: Loss of skills = red flag
Feeding & fluids: Ask about wet nappies - red flag if none >12hrs
Resistant to examination? Alert, active children resist examination - if not, red flag

⚡ Quick Facts

Children make up ~20% of UK population
Clinical workload increased 9% (2007-2014) in <5 years
~25% of patients <18 years visit GP annually
Average GP sees 400-600 children per 6 months
30% of children are frequent attenders (≥4 visits/year)
Rule of Febrile Thirds: 1/3 no more, 1/3 one more, 1/3 repeated bouts
Paediatrics is dangerous - children can deteriorate rapidly
Always provide clear, explicit safety-netting advice
Common outcomes are common, but look for uncommon serious causes
Write instructions down if information is complex

🧠 Memory Aids

ABC + RED BURT (Sick Child Assessment)

ABC: Alertness, Breathing, Colour

RED BURT: Responsiveness, Eye contact, Drinking, Breathing, Urine, Rash, Temperature

SOCRATES (Pain Assessment)

Site, Onset, Character, Radiation, Associations, Time course, Exacerbating factors, Severity

4 T's (Cyanotic Heart Disease)

Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus

NIPE Examination

Eyes, Heart, Hips, Testes (males) - Newborn & Infant Physical Examination

🎯 Clinical Decision Making Framework

Key Insight from Dr Edward Snelson (Consultant Paediatrician):

Most childhood illnesses are too dynamic for a snapshot to be completely valid. It's not just about the current traffic light - it's about how the lights are changing and what you're going to do with that information.

🟢 GREEN Patients

Easy to manage - Clear decision-making

Simple viral URTI
Watchful waiting
Appropriate safety-netting
Reassurance to parents

🔴 RED Patients

Easy to manage - Clear action needed

Meningitis features
Give benzylpenicillin
999 ambulance
Immediate admission

🟡 AMBER Patients

Complex decisions - Requires careful thought

Not quite green, not quite red
Consider trajectory of illness
Multiple management options
Where complexity lies

🤒 The Sick Child

🔍 10-Second Doorway Assessment

Before you even touch the child, observe:

Alertness: Are they aware of their surroundings?
Activity: Playing, interacting, or listless?
Breathing: Any obvious respiratory distress?
Colour: Pink, pale, mottled, or cyanosed?
Crying: Strong cry or weak/high-pitched?

📋 Essential History Questions

Key Questions

Is the child happy or miserable?
Are they drinking normally?
Are they wetting nappies/passing urine?
How is their feeding/appetite?
Are they playing/interacting normally?
How is their sleep pattern?
Any fever? How high? How long?
Any vomiting or diarrhoea?

Parental Concerns

"What are you most worried about?"
"How does this compare to when they're well?"
"What's your gut feeling?"
Previous similar episodes?

🔍 Essential Examination

Always Check

General appearance: Alert vs lethargic
Playfulness: Interacting with toys/parents
Capillary refill: Normal <2 seconds
Hydration status: Mucous membranes, skin turgor
Rash: Full body examination, blanching test
Temperature, heart rate, respiratory rate
Weight (if possible) and growth charts

Age-Specific Considerations

Infants: Fontanelle, feeding, tone
Toddlers: Interaction, walking, speech
School age: Can engage in conversation

⚠️ Red Flag Examination Findings

Circulation

Capillary refill >3 seconds
Mottled/pale skin
Cold peripheries
Weak pulse

Neurological

Reduced consciousness
Floppy tone
Bulging fontanelle
Neck stiffness

Respiratory

Grunting
Severe recession
Cyanosis

📊 Normal Vital Signs by Age

Age	Heart Rate (bpm)	Respiratory Rate (per min)	Systolic BP (mmHg)	Temperature (°C)
Newborn	120-160	30-60	60-90	36.5-37.5
1-12 months	80-140	30-40	70-100	36.5-37.5
1-2 years	80-130	25-35	80-110	36.5-37.5
2-5 years	80-120	20-30	90-110	36.5-37.5
5-12 years	70-110	15-25	90-120	36.5-37.5

🚦 NICE Traffic Light System (NG143 - 2026)

Purpose:

Systematic approach to identify children at low, intermediate, or high risk of serious illness. Use alongside clinical judgment - not a replacement for it.

Assessment Area	GREEN (Low Risk)	AMBER (Intermediate Risk)	RED (High Risk)
Colour	Normal colour of skin, lips and tongue	Pallor reported by parent/carer	Pale/mottled/ashen/blue
Activity	Responds normally to social cues Content/smiles Stays awake or awakens quickly Strong normal cry/not crying	Not responding normally to social cues Wakes only with prolonged stimulation Decreased activity	No response to social cues Appears ill to healthcare professional Does not wake or if roused does not stay awake Weak, high-pitched or continuous cry
Respiratory	Normal breathing pattern	Nasal flaring Tachypnoea: RR >50 if 6-12 months RR >40 if >12 months Oxygen saturation ≤95% in air Crackles in chest	Grunting Tachypnoea: RR >60 Moderate or severe chest indrawing
Circulation & Hydration	Normal skin and eyes Moist mucous membranes	Tachycardia: HR >160 if <12 months HR >150 if 12-24 months HR >140 if 2-5 years CRT ≥3 seconds Dry mucous membranes Poor feeding in infants Reduced urine output	Reduced skin turgor
Other	None of the amber or red symptoms or signs	Fever ≥39°C if 3-6 months Fever for ≥5 days Rigors Swollen limb or joint Non-weight bearing limb/not using an extremity	Age <3 months with fever ≥38°C Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures Bile-stained vomiting

📋 Management by Risk Level

🟢 GREEN - Low Risk

Provide safety netting advice
Arrange follow-up if needed
Consider self-care advice
Paracetamol/ibuprofen for fever

🟡 AMBER - Intermediate Risk

Provide safety netting advice
Consider referral to paediatric specialist
Arrange follow-up within 2-4 hours
Consider further investigations

🔴 RED - High Risk

Urgent referral to paediatric specialist care
Consider 999 ambulance
Do not delay for investigations
Provide immediate supportive care

⚠️ Important Notes:

Use clinical judgment alongside the traffic light system
If any RED features present → high risk regardless of other features
If no RED but any AMBER features → intermediate risk
Parental concern is important - consider even if child appears well
Children can deteriorate rapidly - safety net appropriately

🚨 Paediatric Emergencies

When seconds count and you need to act fast - your emergency protocols

🧠 Meningitis & Septicaemia +

🚨 Emergency Action:

If suspected: Give IM/IV benzylpenicillin immediately, then urgent hospital transfer. Don't delay for investigations.

Clinical Features:

Early Signs

Fever, headache, vomiting
Irritability, lethargy
Poor feeding
High-pitched cry

Late Signs

Non-blanching rash
Neck stiffness
Photophobia
Bulging fontanelle
Reduced consciousness

Drug Dosages:

Age	Benzylpenicillin (IM/IV)	Alternative (Penicillin Allergy)
<1 month	50mg/kg	Cefotaxime 50mg/kg
1-11 months	300mg	Cefotaxime 50mg/kg
1-9 years	600mg	Cefotaxime 50mg/kg (max 1g)
≥10 years	1200mg	Cefotaxime 1g

Remember: Early recognition and immediate action save lives. Don't wait for classic presentations - children can deteriorate rapidly.

⚡ Anaphylaxis +

🚨 Emergency Action:

IM Adrenaline immediately, call 999, lie flat with legs raised, high-flow oxygen, IV access.

Recognition:

Sudden onset after exposure to allergen
Airway: swelling, hoarse voice, stridor
Breathing: wheeze, cyanosis, respiratory distress
Circulation: tachycardia, hypotension, collapse
Skin: urticaria, angioedema, flushing

Adrenaline Dosages (IM):

Age	Adrenaline 1:1000	EpiPen Dose
<6 months	0.05ml (50 micrograms)	-
6 months - 6 years	0.15ml (150 micrograms)	EpiPen Jr (150 micrograms)
6-12 years	0.3ml (300 micrograms)	EpiPen (300 micrograms)
>12 years	0.5ml (500 micrograms)	EpiPen (300 micrograms)

Note: Repeat adrenaline every 5 minutes if no improvement. Give into anterolateral thigh.

🌡️ Febrile Convulsions & Status Epilepticus +

Febrile Convulsions:

Simple Febrile Convulsion

Age 6 months - 5 years
Generalised tonic-clonic
<15 minutes duration
No recurrence in 24 hours
No neurological sequelae

Complex Febrile Convulsion

Focal features
>15 minutes duration
Recurrence within 24 hours
Neurological abnormalities
Requires hospital assessment

Status Epilepticus Management:

Definition: Seizure >5 minutes or repeated seizures without recovery

Time	Action	Drug & Dose
0-5 mins	ABC, recovery position, oxygen, glucose	-
5-10 mins	First line anticonvulsant	Midazolam 0.5mg/kg buccal (max 10mg) OR Diazepam 0.5mg/kg PR (max 20mg)
10-15 mins	Second dose if still fitting	Repeat midazolam or diazepam
15+ mins	Call anaesthetist, prepare for intubation	IV phenytoin 20mg/kg or levetiracetam 40mg/kg

🫁 Severe Asthma & Respiratory Emergencies +

Acute Severe Asthma:

Severity	Clinical Features	Peak Flow
Moderate	Able to talk in sentences, some breathlessness	50-75% predicted
Severe	Can't complete sentences, HR >125, RR >30	33-50% predicted
Life-threatening	Silent chest, cyanosis, exhaustion, confusion	<33% predicted

Treatment Protocol:

First Line

High-flow oxygen (if SpO2 <94%)
Salbutamol 2.5-5mg nebulised
Prednisolone 1-2mg/kg PO (max 40mg)
Repeat salbutamol every 20 mins

Second Line

Ipratropium 250 micrograms nebulised
IV magnesium sulphate 40mg/kg (max 2g)
Consider IV aminophylline
Senior help/ITU referral

Life-threatening Features:

Silent chest, poor respiratory effort
Cyanosis, SpO2 <92%
Exhaustion, confusion, reduced consciousness
Hypotension, bradycardia

🍯 Diabetic Ketoacidosis (DKA) +

🚨 Emergency - Always Hospital Referral:

DKA in children is a medical emergency. Cerebral oedema is a life-threatening complication.

Diagnostic Criteria:

Hyperglycaemia (glucose >11 mmol/L)
Ketonaemia (blood ketones >3 mmol/L)
Acidosis (pH <7.3 or bicarbonate <15 mmol/L)

Clinical Features:

Early Signs

Polyuria, polydipsia
Weight loss
Nausea, vomiting
Abdominal pain

Late Signs

Dehydration
Kussmaul breathing
Ketotic breath
Reduced consciousness

⚠️ Cerebral Oedema Warning Signs:

Headache, irritability
Reduced consciousness
Focal neurological signs
Bradycardia, hypertension

🩺 CLINICAL STUFF

🤒 The Sick Child

Comprehensive assessment and management of unwell children - see dedicated tab above for full details.

🦠 Childhood Infections

Exanthemata (Childhood Rashes)

Disease	Rash Description	Other Features	Complications
Measles	Maculopapular, starts behind ears, spreads down	Koplik spots, high fever, cough, conjunctivitis	Pneumonia, encephalitis
Rubella	Fine pink rash, face to body	Lymphadenopathy, mild fever	Congenital rubella syndrome
Chickenpox	Vesicular, crops, different stages	Fever, malaise, itching	Secondary bacterial infection
Fifth Disease (Slapped Cheek)	Slapped cheek, lacy rash on body	Mild fever, arthralgia	Aplastic crisis in sickle cell
Roseola	Rose-pink rash after fever settles	High fever 3-4 days, then rash	Febrile convulsions

Slapped Cheek Disease (Fifth Disease)

Cause: Parvovirus B19

Clinical Features:

Bright red rash on both cheeks (slapped cheek appearance)
Lacy, reticular rash on trunk and limbs
Mild fever, malaise
Joint pain in adults

Management: Supportive care, exclude from school until well

Complications: Aplastic crisis in sickle cell disease, fetal hydrops if pregnant

Henoch-Schönlein Purpura (HSP)

Presentation:

Age: Peak 4-6 years, mainly 2-10 years
Incidence: 10-20 per 100,000 children annually
Trigger: Often follows URTI (2-3 weeks prior)
Season: More common in autumn/winter

Clinical Features:

Rash: Purpuric, non-blanching, symmetrical
Distribution: Buttocks, legs, extensor surfaces
Arthritis: Knees, ankles (70%)
Abdominal pain: Colicky (50-75%)
Renal: Haematuria, proteinuria (20-50%)

🫁 Common Acute Conditions

Bronchiolitis vs Croup

Feature	Bronchiolitis	Croup
Age	Usually <2 years, peak 2-6 months	6 months - 6 years, peak 1-2 years
Cause	RSV (80%), parainfluenza, adenovirus	Parainfluenza virus (75%), RSV, adenovirus
Pathology	Small airway inflammation and obstruction	Laryngeal and tracheal inflammation
Key Features	Dry cough, wheeze, fine crackles	Barking cough, inspiratory stridor, hoarse voice
Treatment	Supportive care only	Dexamethasone 0.15mg/kg PO for moderate/severe

🤢 Abdominal Pain

Intussusception

Age: Peak 6-18 months, 90% <2 years

Clinical Features:

Severe colicky abdominal pain
Vomiting (may be bile-stained)
Redcurrant jelly stools (late sign)
Palpable sausage-shaped mass
Lethargy between episodes

Action: Urgent surgical referral - can lead to bowel necrosis

🏥 Chronic Conditions

Long-term conditions requiring ongoing management and monitoring.

🧬 Congenital & Genetic

Inherited conditions and congenital abnormalities.

🫘 GI & Renal

Gastrointestinal and renal conditions in children.

🦴 MSK & Neuro

Musculoskeletal and neurological conditions.

🌸 Dermatology

Common skin conditions in paediatric patients.

🧠 Learning Disability

Assessment and support for children with learning difficulties.

😴 Sleep

Normal Sleep Requirements

Age	Total Sleep (24hrs)	Night Sleep	Daytime Naps	Common Issues
Newborn	14-17 hours	Irregular	Multiple	Day/night confusion
3-6 months	12-15 hours	6-8 hours	3-4 naps	Sleep regression
6-12 months	12-14 hours	10-12 hours	2-3 naps	Separation anxiety
1-2 years	11-14 hours	10-12 hours	1-2 naps	Bedtime resistance
3-5 years	10-13 hours	10-13 hours	0-1 nap	Nightmares, fears

Sleep Hygiene & Management

Good Sleep Hygiene

Consistent bedtime routine
Regular sleep/wake times
Comfortable sleep environment
Avoid screens before bedtime
Appropriate room temperature
Comfort objects (transitional objects)

Common Sleep Problems

Bedtime resistance: Consistent routine, gradual retreat
Night waking: Controlled crying, gradual extinction
Early morning waking: Later bedtime, blackout curtains
Nightmares: Reassurance, address fears
Night terrors: Don't wake, ensure safety

👶 The Normal Child

Understanding normal development, growth, and behaviour

Key Principle:

Normal development has wide variation. Focus on overall pattern and trajectory rather than isolated delays. Parental concern is always significant.

Normal Physical Development

Growth Patterns:

Birth weight: Regained by 10-14 days
0-3 months: 150-200g/week weight gain
3-6 months: 100-150g/week weight gain
6-12 months: 70-90g/week weight gain
Length: 25cm in first year, 12cm in second year
Head circumference: 12cm in first year

Normal Variations:

Physiological jaundice: Days 2-14
Mongolian spots: Blue-grey birthmarks
Milia: White spots on nose
Erythema toxicum: Newborn rash
Caput succedaneum: Scalp swelling
Positional talipes: Flexible foot deformity

Faltering Growth:

Definition: Sustained drop of 2 centile spaces over 2 weighing intervals on WHO growth chart

Essential feeding patterns and volumes for healthy infant development

Key Principle: As babies get older, they settle into more predictable feeding routines and go longer stretches at night without needing feeds.

Feeding Guidelines by Age:

Age	Volume per Feed	Frequency	Notes
First few days	1.5-3 oz (45-90ml)	Every 2-3 hours	Small, frequent feeds
About 2 months	4-5 oz (120-150ml)	Every 3-4 hours	Establishing routine
About 4 months	4-6 oz (120-180ml)	At each feeding	More predictable pattern
About 6 months	6-8 oz (180-230ml)	4-5 times per day	Weaning may begin

Signs of Adequate Feeding:

Regular wet nappies (at least 6 per day after day 5)
Steady weight gain
Content between feeds
Alert and active when awake
Good skin colour and tone

Red Flags - Feeding Concerns:

No wet nappy for >12 hours
Poor feeding or refusing feeds
Excessive weight loss (>10% birth weight)
Lethargic or difficult to rouse
Persistent vomiting
Signs of dehydration

Important History Questions:

"How is feeding going?" - Open question first
"How much are they taking?" - Specific volumes
"How often are they feeding?" - Frequency pattern
"When did they last have a wet nappy?" - Hydration status
"Any vomiting or bringing up feeds?" - Retention
"How are they between feeds?" - Contentment

Developmental Milestones

Age	Gross Motor	Fine Motor & Vision	Speech & Hearing	Social & Personal
6 weeks	Holds head up briefly when prone	Follows face/bright object	Coos and gurgles	Social smile
3 months	Good head control when held	Holds rattle briefly when placed in hand	Babbles, laughs	Laughs and squeals with pleasure
6 months	Sits with support, rolls	Transfers objects hand to hand	Double syllables (mama, dada - no meaning)	Stranger awareness begins
9 months	Sits without support, crawls	Pincer grip developing	Says mama/dada with meaning	Waves bye-bye, plays peek boo
12 months	Walks with support (cruising)	Neat pincer grip	First words (2-3 words)	Points to share interest
18 months	Walks independently, runs	Tower of 3 blocks, scribbles	10-20 words, understands simple commands	Symbolic play (feeds doll)
2 years	Runs well, kicks ball, jumps	Tower of 6 blocks, circular scribble	50+ words, 2-word phrases	Parallel play, temper tantrum
3 years	Pedals tricycle, stands on one foot	Copies circle, uses scissors	Sentences, asks questions	Group play, toilet trained

Red Flags for Developmental Delay:

Motor Development:

Not sitting by 12 months
Not walking by 18 months
Loss of previously acquired skills
Persistent primitive reflexes
Significant asymmetry

Speech & Language:

No babbling by 12 months
No words by 18 months
No 2-word phrases by 2 years
Speech not understood by strangers by 3 years
Regression in language skills

Emotional & Psychological Development

Age	Normal Behaviour	Common Concerns	When to Worry
0-6 months	Crying peaks at 6 weeks, settles by 3-4 months	Colic, sleep patterns	No social smile by 8 weeks
6-12 months	Stranger anxiety, separation anxiety	Sleep regression, feeding issues	No babbling by 12 months
1-2 years	Tantrums, negativism, parallel play	Toilet training, behaviour	No words by 18 months
2-5 years	Imaginative play, questions, fears	Behaviour, sleep issues	No pretend play by 3 years

Newborn Blood Spot (Guthrie):

Day 5-8 of life
PKU (phenylketonuria)
Congenital hypothyroidism
Cystic fibrosis
Sickle cell disease
MCADD (metabolic disorder)

Hearing Screening:

Within first few weeks
Automated otoacoustic emissions (AOAE)
Automated auditory brainstem response (AABR)
Refer if not clear response

NIPE Examination:

Within 72 hours of birth
Eyes (cataracts, red reflex)
Heart (murmurs, pulses)
Hips (developmental dysplasia)
Testes (undescended)

UK Immunisation Schedule 2026

Key Principle: Immunisation is one of the most effective public health interventions. Follow the UK schedule and address parental concerns with evidence-based information.

Age	Vaccines	Route	Site
8 weeks	6-in-1 (DTaP/IPV/Hib/HepB), Rotavirus, MenB, PCV13	IM, Oral, IM, IM	Anterolateral thigh
12 weeks	6-in-1, Rotavirus, PCV13	IM, Oral, IM	Anterolateral thigh
16 weeks	6-in-1, MenB, PCV13	IM, IM, IM	Anterolateral thigh
1 year	Hib/MenC, MMR, PCV13, MenB	IM, IM, IM, IM	Anterolateral thigh/deltoid
3y 4m	4-in-1 (DTaP/IPV), MMR	IM, IM	Deltoid

Administration Guidelines

Injection Sites:

<12 months: Anterolateral thigh
>12 months: Deltoid muscle
Needle size: 25G, 16mm (thigh), 23G, 25mm (deltoid)
Multiple vaccines: Different limbs, 2.5cm apart

Contraindications:

Absolute: Anaphylaxis to previous dose
Live vaccines: Immunocompromised, pregnancy
Temporary: Acute febrile illness
NOT contraindications: Minor illness, antibiotics, family history

Adverse Events

Common (Expected)

Local redness, swelling
Low-grade fever
Irritability
Reduced appetite

Uncommon

High fever >39°C
Febrile convulsion
Extensive limb swelling
Persistent crying

Rare (Emergency)

Anaphylaxis
Severe allergic reaction
Intussusception (rotavirus)
Report to MHRA Yellow Card

Essential procedures and measurements in children

Accurate Measurements

Blood Pressure:

Cuff size: 2/3 of upper arm length
Position: Sitting, arm at heart level
Normal values: Age-specific charts
Hypertension: >95th centile for age/height

Peak Flow:

Age: Usually >5 years
Technique: Standing, deep breath, sharp blow
Best of 3: Record highest value
Normal values: Height/age specific

Growth Measurements:

Weight: Naked <2 years, minimal clothing >2 years
Length: Lying flat <2 years
Height: Standing >2 years, shoes off
Head circumference: Largest occipitofrontal circumference

Venepuncture in Children

Preparation:

Topical anaesthetic: EMLA, Ametop (45-60 mins)
Distraction: Toys, bubbles, music
Position: Parent's lap, comfortable
Explain: Age-appropriate language

Technique:

Sites: Antecubital fossa, dorsal hand veins
Needle: 23G butterfly or straight needle
Restraint: Minimal, gentle holding
Reward: Sticker, praise

Pain Relief:

Sucrose: 0.5ml 24% solution (neonates)
Breastfeeding: During procedure if possible
Paracetamol: Pre-procedure if very anxious

Remember: You've Got This!

📚 Resources & Downloads

🔗 Clinical Guidelines

NICE Guidelines

Evidence-based clinical guidelines for paediatric care

Visit NICE Paediatric Guidelines

RCPCH Growth Charts

UK-WHO growth charts for monitoring child development

Download Growth Charts

Immunisation Schedule

Current UK immunisation schedule and guidance

View Schedule

Safeguarding Resources

Child protection guidance and procedures

Access Resources

Emergency Drug Doses

Quick reference for paediatric emergency medications

View Guidelines

📱 Clinical Tools

Paediatric Early Warning Score

PEWS calculator for risk assessment

Calculate PEWS

Centile Calculator

Online tool for growth centile calculations

Use Calculator

Developmental Screening

ASQ and other developmental assessment tools

Access Tools

Drug Dosage Calculator

Weight-based paediatric drug calculations

Calculate Doses

Parent Information Leaflets

Downloadable patient information resources

Download Leaflets

Same-Day Referral Criteria

Clear criteria for urgent paediatric referrals

View Criteria

🛡️ Safeguarding

Recognising abuse, understanding procedures, and protecting vulnerable children

Please note: There is a whole Bradford VTS webpage devoted to Child Safeguarding. This section is a small summary of key points for quick reference.

Physical Abuse Red Flags:

Injury Patterns

Delay in seeking medical attention
Story inconsistent with injuries
Repeated attendances with injuries
Unusual pattern of injuries
Injuries in non-mobile child
Bruising in protected areas
Grip marks, bite marks
Burns with clear demarcation
Fractures in non-mobile child

Emotional/Behavioural Indicators

Frozen watchfulness in child
Inappropriate child-parent interaction
Parent more concerned about themselves
Excessive compliance or aggression
Developmental regression
Self-harm behaviours
Sexualised behaviour (inappropriate for age)

Risk Factors:

Parental Factors

Substance misuse
Mental health problems
Domestic violence
Social isolation
Young parents
History of abuse

Child Factors

Disability
Chronic illness
Premature birth
Difficult temperament

🚨 Action Required - If Concerned:

Discuss with safeguarding lead
Contact children's services
Document everything
Follow local procedures
Consider immediate safety

Documentation Requirements:

Date, time, location
Who was present
Objective description of injuries
Exact quotes (child and parent)
Your observations and concerns
Actions taken

Remember:

Your role is to identify concerns and refer appropriately. You are not expected to investigate or prove abuse. When in doubt, seek advice from your safeguarding lead or children's services.

Same-Day Referrals to Paediatrics

Remember: When in doubt, refer!
It's better to refer a well child than miss a sick one. Paediatric teams expect and welcome appropriate referrals.

🚨 Immediate 999 Ambulance

Anaphylaxis
Status epilepticus
Severe respiratory distress
Shock/circulatory failure
Reduced consciousness
Major trauma

🏥 Urgent Same-Day Referral

Fever <3 months
Non-blanching rash
Bile-stained vomiting
Severe dehydration
Suspected meningitis
Diabetic ketoacidosis
Acute severe asthma

📞 Discuss with Paediatrics

NICE traffic light AMBER features
Parental concern + clinical worry
Diagnostic uncertainty
Social concerns
Failure to respond to treatment

Referral Information to Include:

Clinical Details

Age, weight if known
Duration of illness
Key symptoms and signs
Vital signs including temperature
Feeding/fluid intake
Urine output

Background

Birth history if relevant
Past medical history
Current medications
Immunisation status
Family history
Social circumstances